A recent three-part article published in ACA News advocates turning chiropractors into “conservative primary care providers” who would be the initial point of contact for patients, would serve as gatekeepers for referrals to medical doctors and specialists, and would co-manage patients with those specialists on a continuing basis: essentially, family doctors. I think that’s a terrible idea. It might benefit chiropractors by increasing their market share, but it wouldn’t benefit patients. There is no evidence to indicate that chiropractors are capable of filling that role effectively or safely.

NUHS. The article was co-authored by several chiropractors on the faculty of the National University of Health Sciences, a school noted for integrating quackery with medicine. The “sciences” this school teaches are listed at the top of its website: chiropractic medicine, naturopathic medicine, oriental medicine, acupuncture, biomedical science, and massage therapy. The only one of those that even sounds like science, “biomedical science,” offers a bachelor of science degree with an integrative medicine focus and with no required core courses whatsoever!

Their doctor of chiropractic degree program says:

National University prepares students to become first-contact, primary care physicians fully qualified to diagnose, treat and manage a wide range of conditions.

If there’s one thing about quacks, it’s that they are profoundly hostile to science. Actually, they have a seriously mixed up view of science in that they hate it because it doesn’t support what they believe. Yet at the same time they very much crave the imprimatur that science provides. When science tells them they are wrong, they therefore often try to attack the scientific method itself or claim that they are the true scientists. We see this behavior not just in quackery but any time scientific findings collide with entrenched belief systems, for example, medicine, evolution, anthropogenic global warming, and many others. So it was not surprising that a rant I saw a few weeks ago by a well-known supporter of pseudoscience who blogs under the pseudonym of Vox Day caught my interest. Basically, he saw a news report about an article in Nature condemning the quality of current preclinical research. From it, he draws exactly the wrong conclusions about what this article means for medical science:

Fascinating. That’s an 88.6 percent unreliability rate for landmark, gold-standard science. Imagine how bad it is in the stuff that is only peer-reviewed and isn’t even theoretically replicable, like evolutionary biology. Keep that figure in mind the next time some secularist is claiming that we should structure society around scientific technocracy; they are arguing for the foundation of society upon something that has a reliability rate of 11 percent.

Now, I’ve noted previously that atheists often attempt to compare ideal science with real theology and noted that in a fair comparison, ideal theology trumps ideal science. But as we gather more evidence about the true reliability of science, it is becoming increasingly obvious that real theology also trumps real science. The selling point of science is supposed to be its replicability… so what is the value of science that cannot be repeated?

No, a problem with science as it is carried out by scientists in the real world doesn’t mean that religion is true or that a crank like Vox is somehow the “real” intellectual defender of science. Later, Vox doubles down on his misunderstanding by trying to argue that the problem in this article means that science is not, in fact, “self-correcting.” This is, of course, nonsense in that the very article Vox is touting is an example of science trying to correct itself. Be that at it may, none of this is surprising, given that Vox has demonstrated considerable crank magnetism, being antivaccine, anti-evolution, an anthropogenic global warming denialist, and just in general anti-science, but he’s not alone. Quackery supporters of all stripes are jumping on the bandwagon to imply that this study somehow “proves” that the scientific basis of medicine is invalid. A writer at Mike Adams’ wretched hive of scum and quackery, NaturalNews.com, crows:

Begley says he cannot publish the names of the studies whose findings are false. But since it is now apparent that the vast majority of them are invalid, it only follows that the vast majority of modern approaches to cancer treatment are also invalid.

But does this study show this? I must admit that it was a topic of conversation at the recent AACR meeting, given that the article was published shortly before the meeting. It’s also been a topic of e-mail conversations and debates at my very own institution. But do the findings reported in this article mean that the scientific basis of cancer treatment is so off-base that quackery of the sort championed by Mike Adams is a viable alternative or that science-based medicine is irrevocably broken?

Although I write the definitive entries on topics in this blog, new information trickles in after publication. The new studies are often not worth an entire entry, recapitulating prior essays, but the new information is still worth a mention. What follows are updates on topics covered in prior SBM posts.

In Oregon we are having a small outbreak of infections from consumption of raw milk. Not a surprise, since milk is a wonderful culture media and the udder is just down the gravity well from the cows anus. Raw milk violates the classic dictum “Don’t shit where you eat” although I understand the saying concerned dating in its original conception.

Although the sale of raw milk is illegal in muchof the US, the law can be bypassed by owning the cow rather than buying the milk, a reverse of dating advice. Such is the case in Oregon, where 48 people are time sharing the cows responsible for the current outbreak. There has been the spread of pathogenic E. coli to at least 5 people, mostly children, and has lead to the hospitalization of at least 3 children.

Of course, it is hard to get infected. Humans have lived in Filth and Squalor (like Minneapolis and St. Paul or Buda and Pest) for centuries, drinking and eating contaminated food and enough survived perpetuate the species. Most infections in the past would have been from consuming contaminated food and drink. I have wondered if the reason fevers are often associated with diarrhea and/or vomiting is that it an evolved response for removing infected material as soon as possible.(more…)

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Five consumer lawsuits are pending in the U.S. against Boiron, the world’s largest manufacturer of homeopathic products. One lawsuit is also pending in Canada. As reported in a previous post, the U.S. plaintiffs claim they purchased homeopathic products, such as Coldcalm, Oscillo, Arnicare and Chestal Cough Syrup, based on Boiron’s misleading and false statements that they are effective for various ailments. Therefore, these plaintiffs allege, Boiron has defrauded consumers, as well as violated various consumer protection laws. Boiron denies these claims.

we can summarize . . . by saying it has extreme implausibility and the clinical evidence shows lack of efficacy. It should not work, and it does not work. There is no legitimate controversy about this.

Which raises an interesting question: how does one defend a product that appears to be indefensible? Let’s take a look. (more…)

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All scientists should be skeptics. Serious problems arise when a less-than-skeptical approach is taking to the task of discovery. Typically the result is flawed science, and for those significantly lacking in skepticism this can descend to pseudoscience and crankery. With the applied sciences, such as the clinical sciences of medicine and mental therapy, there are potentially immediate and practical implications as well.

Clinical decision making is not easy, and is subject to a wide range of fallacies and cognitive pitfalls. Clinicians can make the kinds of mental errors that we all make in our everyday lives, but with serious implications to the health of their patients. It is therefore especially important for clinicians to understand these pitfalls and avoid them – in other words, to be skeptics.

It is best to understand the clinical interaction as an investigation, at least in part. When evaluating a new patient, for example, there is a standard format to the “history of present illness,” past medical history, and the exam. But within this format the clinician is engaged in a scientific investigation, of sorts. Right from the beginning, when their patient tells them what problem they are having, they should be generating hypotheses. Most of the history taking will actually be geared toward testing those diagnostic hypotheses.

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Eric Topol, MD, has written a book about the convergence of the digital revolution and medicine. It is full of fascinating information and prognostication, but I wish he had given it a better title. He called it The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Medicine will not and cannot be “destroyed.” It will be improved and transformed, perhaps, but not destroyed. And any new developments will have to be evaluated for safety and effectiveness by the good old time-tested methods of science.

The future world of medicine is really exciting: science fiction is becoming real. As I read Topol’s book I serendipitously found it paraphrased by a character in another book I was reading, Chop Shop, by Tim Downs.

I see a world where no one ever dies from an adverse drug reaction; where physicians have an entire range of medicines to choose from to treat a deadly disease; where medications target tumors like smart bombs and leave surrounding tissues unharmed; where genetic susceptibility to disease can be determined in childhood, and possibly even prevented.

(If you haven’t yet discovered Downs’ hilarious “Bug Man” detective series about a crazy forensic entomologist, you have a treat in store.)

But back to non-fiction. Our world is changing almost too rapidly to comprehend: the Internet reaches everywhere, and there are far more mobile phones in the world today than toilets. We have hardly begun to tap the current potential of new technologies, and unimagined further developments await us. Topol is a qualified guide to this new world: he is a respected cardiologist and geneticist who ha s been on the forefront of wireless medicine and who was a major whistleblower in the Vioxx fiasco. He knows whereof he speaks, and he writes lucidly and accessibly.(more…)

The U.S. is widely known to have the highest health care expenditures per capita in the world, and not just by a little, but by a lot. I’m not going to go into the reasons for this so much, other than to point out that how to rein in these costs has long been a flashpoint for debate. Indeed, most of the resistance to the Patient Protection and Affordable Care Act (PPACA), otherwise known in popular parlance as “Obamacare,” has been fueled by two things: (1) resistance to the mandate that everyone has to buy health insurance, and (2) the parts of the law designed to control the rise in health care costs. This later aspect of the PPACA has inspired cries of “Rationing!” and “Death panels!” Whenever science-based recommendations are made that suggest ways to decrease costs by reevaluating screening tests or decreasing various tests and interventions in situations where their use is not supported by scientific and clinical evidence, whether by the government or professional societies, you can count on it not being long before these cries go up, often from doctors themselves.

My perspective on this issue is that we already “ration” care. It’s just that government-controlled single payer plans and hybrid private-public universal health care plans use different criteria to ration care than our current system does. In the case of government-run health care systems, what will and will not be reimbursed is generally chosen based on evidence, politics, and cost, while in a system like the U.S. system what will and will not be reimbursed tends to be decided by insurance companies based on evidence leavened heavily with business considerations that involve appealing to the largest number of employers (who, let’s face it, are the primary customers of health insurance companies, not individuals insured by their health insurance plans). So what the debate is really about is, when boiled down to its essence, how to ration care and by how much, not whether care will be rationed. Ideally, how funding allocations are decided would be based on the best scientific evidence in a transparent fashion.

The study I’m about to discuss is anything but the best scientific evidence.(more…)

Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.

Something to Consider When You have Back Pain

Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.

It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.

Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.

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One of the recurrent themes in alternative medicine is the practice of simplifying complex medical conditions, and then offering up equally simple solutions which are positioned as still being within the realm of science. This approach allows the practitioner to ignore all of the complexity and difficulty of practicing real medicine, yet offer nostrums that, on first glance, can sound legitimate. Science-y, even.

I’ve discussed this before in non-science-based approaches to food intolerances, whether it’s using clinically useless IgG blood tests, or declaring the universal dietary enemy to be gluten. David Gorski elaborated on the same theme just a few days ago in the context of cancer treatment, contrasting the simplistic views of alternative medicine purveyors with the facts of cancer research. Cancer is stunningly complex – each of the hundreds of different variants of the disease. I’m always amazed when I speak with oncologists about how treatment regimens have been established. They describe how the results of dozens of clinical trials, led by different trial groups around the world have each contributed to establishing the current “best” regimens for each cancer: the appropriate drugs, doses, intervals and treatment intensities. Good evidence speaks all languages, and as new data emerges, practices change quickly to build upon whatever new evidence has emerged. The complexity of treatments continue to increase. Overlay the genetic and genomic complexity David described, and you get a sense of the challenges (and opportunities) cancer researchers face in order for science continue to improve outcomes for patients with cancer.

So it’s a bit of a shock when you shift your attention to the alternative medicine “literature”, where simple solutions abound. One that’s popular among patients I speak with, particularly those with European backgrounds, is the use of what are called systemic enzymes – enzymes, consumed orally, with the intent of whole-body effects. These products are not used as part of “conventional” medicine but are popular supplements recommended by alternative practitioners. I was recently asked about a product called Wobenzym N, a product with German roots which is advertised with the following claims [PDF]: (more…)

It has been a stunning triumph of marketing and propaganda that many people believe that treatments that are “natural” are somehow magically safe and effective (an error in logic known as the naturalistic fallacy). There is now widespread belief that herbal remedies are not drugs or chemicals because they are natural. The allies in Congress of those who sell such products have even passed laws that embody this fallacy – taking herbal remedies away from FDA oversight and regulating them more like food than drugs.

The other major fallacy spread by the “natural remedy” industry is that if a product has been used for a long time (hundreds or thousands of years), then it must also be safe and effective because it has stood the test of time (this fallacy is referred to as the argument from antiquity). This fallacy even has a specific regulatory term to invoke it – GRAS or “generally recognized as safe.” With food and food ingredients the FDA does not require evidence of safety if the ingredient is generally recognized as safe. This might make sense when referring to foods that have be eaten by humans for a long time. Although the logic is still dubious, it’s just practical – the FDA could not take upon itself the task of proving that every food eaten by humans has no significant negative health consequences. It is more a recognition of practicality than reality.